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Tier - Description

1 - This drug is available at the lowest co-pay. Most commonly, these are generic drugs.2 - This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs. For this standard benefit design, drugs at this level are frequently considered to have a lowest branded copay (LBC).3 Preferred – This drug is available at a preferred co-pay. Most commonly used when tiers 1 and 2 apply to preferred generic and non-preferred generic drugs, respectively. For this benefit design, drugs at this level are frequently considered to have a lowest branded copay (LBC).3 - This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.4 - This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.5 - This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.6 - This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.7 - This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.NC - Not Covered. Drugs that are not covered by the plan.N/A - Not Available. Formulary data for this drug/health plan are not available.

Restriction Code - Description

PA - Prior Authorization.Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.QL - Quantity Limits.Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of drug that will be covered.ST - Step Therapy.Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.OR - Other Restrictions.Drugs that have restrictions other than prior authorization, quantity limits, and step therapy associated with each prescription.

Formulary Status - Description

Preferred – The status assigned to a drug based on the benefit design of the chosen formulary. This status is usually associated with the lowest tier for a brand or generic drug; or is a designation given to a drug following review by a Pharmacy Committee.Covered – The status assigned to a drug that is not reviewed for inclusion on the Preferred Drug List but is covered by the state.Non-Preferred - The status assigned to a drug based on the benefit design of the chosen formulary. This status is usually associated with the highest tier for a brand or generic drug; or is a designation given to a drug following review by a Pharmacy Committee.Specialty – The status given to a specialty product when it is covered with a copay/co-insurance dedicated to specialty drugs. Specialty drugs are usually injectable, require special handling, or are expensive.Medical – The status given to a drug covered under the medical benefit.Not Covered - Drugs that are not covered by the plan.Not Available - Formulary data for this drug/health plan are not available.